ACL Grafts: Diameter Does Matter, Sort Of
Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.
In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.
However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.
One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.
Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Let’s Continue Improving Hip-Implant Longevity
In October 2017, JBJS published results from a 10-year randomized controlled trial by Devane et al. documenting the dramatic reduction in polyethylene wear in total hip arthroplasties (THAs) using highly cross-linked polyethylene (HXLPE). This followed decades of research documenting that wear debris was implicated in macrophage activity that was ultimately responsible for implant loosening. In the September 4, 2019 issue of The Journal, Hart and colleagues produce further evidence of the improved performance of HXLPE, this time showing revision rates among THA patients with osteonecrosis that rival the rates among patients with osteoarthritis.
In this matched cohort of 922 THAs performed from 1999 to 2007 that used an HXLPE bearing, the 15-year cumulative rate of revision was 6.6% among patients treated for osteonecrosis and 4.5% among patients treated for osteoarthritis (p = 0.09). There were no radiographic signs of component loosening in the entire cohort, and, despite a lower median preoperative Harris hip score (HHS) among patients with osteonecrosis, both groups had marked improvements in HHS score. These findings are especially noteworthy because patients with osteonecrosis typically undergo THA at an earlier age and have much higher functional demands than the typical 70- or 80-year-old osteoarthritis patient.
However, the 15-year revision rate—even with HXLPE—remains at 4.5% for osteoarthritis patients, which should provide impetus to continue our work identifying all possible factors and mechanisms that lead to THA revision. A partial list would include bearing-surface wear, reliability of implantation, biomechanics, biomaterials, and patient perception of postoperative pain. Also, in a subgroup analysis, Hart et al. found that the 15-year rate of any reoperation among osteonecrosis patients ranged from 0% for hips with radiation-induced osteonecrosis to 25% for hips with idiopathic osteonecrosis. These findings add to the list of factors for THA success that need further investigation.
The work list for improvements in THA will remain substantive for at least the next few decades, and we may never get to 0% revisions for all patients. But we have certainly demonstrated that our research can produce very worthwhile results.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Dual-Mobility Cups Lower Revision Risk in Some THAs
OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The Journal of Bone & Joint Surgery, the following commentary comes from Matthew Deren, MD.
Early or late dislocation after total hip arthroplasty (THA) is a dreaded complication, and performing a THA to treat a hip fracture is known to increase the risk of postoperative prosthetic joint dislocation. Large-diameter femoral heads, like those used in metal-on-metal implants, offered the prospect of decreased risk of dislocation. Unfortunately, their promise of improved stability was subsequently offset by serious issues with wear. Orthopaedics is notable for technology that promised to solve one problem but led to another, and some wonder whether the increasing popularity of THA using dual-mobility cups to reduce dislocation risk might lead to another example of this paradoxical problem.
However, in the July 17, 2019 issue of The Journal, Jobory et al. published a population-based prospective cohort analysis based on data from the Nordic Arthroplasty Register Association. That study demonstrated a reduced revision risk with dual-mobility acetabular components when THA was performed to treat hip fracture in elderly patients. The authors propensity-score matched 4,520 hip fractures treated with dual-mobility THA to 4,520 hip fractures treated with conventional THA. The study included surgeries from 2001 to 2014, and the median follow-up was 2.4 years for all patients.
Dual-mobility constructs had a lower overall risk of any-component revision (hazard ratio of 0.75), which persisted after authors adjusted for surgical approach (hazard ratio of 0.73). Additionally, the dual-mobility construct had a lower risk of revision due to dislocation (hazard ratio of 0.45), but there was no difference in risk of deep infection between the cohorts. There was no significant difference in risk of any-component revision for aseptic loosening (hazard ratio of 0.544, p=0.052) until the authors adjusted for approach, which resulted in a decreased risk of any-component revision for aseptic loosening (hazard ratio of 0.500, p=0.030). When the authors compared revision of the acetabular component only, they found a reduced risk of revision for any cause as well as revision for dislocation in the dual-mobility cohort using both unadjusted data and data adjusted for surgical approach. Mortality was higher in the dual-mobility group compared with the conventional-component group (hazard ratio of 1.5).
Overall, this study gives us more information regarding the short-term revision risks of an implant design that is gaining popularity in the US. Although dual-mobility constructs seem to be associated with a decreased risk of revision for dislocation in a population of older adults with hip fracture, this data tells us little about this design and technology when used in younger, more active patients, who are at higher risk of polyethylene wear.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
Study Supports Routine Patellar Resurfacing during TKA
The July 17, 2019 issue of The Journal features another investigation evaluating patellar resurfacing. Despite much research (see related OrthoBuzz post), this topic remains controversial among many total knee arthroplasty (TKA) surgeons. This study, by Vertullo et al., analyzed data from the Australian Orthopaedic Association National Joint Replacement Registry. The findings suggest that routine resurfacing of the patella reduces the risk of revision surgery for TKA patients.
The authors evaluated more than 136,000 TKA procedures after placing the cases into three groups based on the surgeon’s patellar-resurfacing preference: infrequent (<10% of the time), selective (10% to 90% of the time), or routine (≥90% of the time). All of the cases evaluated utilized minimally stabilized components and cemented or hybrid fixation techniques, and they all were performed by surgeons who completed at least 50 TKAs per year.
The authors found that patients in the infrequent-resurfacing cohort had a nearly 500% increased risk of undergoing subsequent patellar revision during the first 1.5 years after TKA, compared to those in the routine-resurfacing cohort. Even more surprising to me was the finding that patients in the selective-resurfacing cohort had a >300% increased risk of needing a patellar revision within the first 1.5 years, compared to those in the routine-resurfacing cohort. In addition, the risk of all-cause revision was 20% higher in the selective cohort compared to the routine cohort.
What struck me most about this study were the differences between the selective and routine cohorts. One of the arguments against routine resurfacing of the patella is that surgeons should decide intra-operatively, on a patient-by-patient basis, whether the osteochondral health and biomechanics of the native patella warrant resurfacing. The findings of Vertullo et al. seem to call that reasoning into question. Although the results of this study add to the evidence supporting the routine resurfacing of the patella during TKA, I would like to reiterate a proviso from my earlier post on this topic: resurfacing is associated with added costs and an increased risk of potential complications.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Durability of Constrained Liners in Revision THA
The indications for treating total hip arthroplasty (THA) dislocations by cementing a constrained polyethylene liner into a well-fixed, retained acetabular component at the time of revision are narrow. That’s largely due to concerns about the durability of the resulting acetabular construct. Now, thanks to a study by Brown et al. in the April 3, 2019 issue of JBJS, hip surgeons have some hard data about the long-term outcomes of this approach.
After reviewing 125 cases in which a constrained liner was cemented into a retained, osseointegrated acetabular component during revision THA, with a mean follow-up of 7 years, the authors found that:
- Survivorship free from revision for instability was 86% at 5 years and 81% at 10 years. The cumulative incidence of instability at 7 years was 18%.
- Survivorship free from aseptic acetabular component revision was 78% at 5 years and 65% at 10 years. The most common failure mechanism was dissociation of the constrained liner from the retained component.
- Harris hip scores (HHS) did not improve significantly after revision. This finding is consistent with prior research that shows better post-revision HHS scores in patients whose revisions include the entire acetabular component.
- Position of the retained cup did not affect implant survivorship or risk of dislocation.
The authors mention alternative strategies for reducing the risk of dislocation after revision THA, such as the use of large-diameter heads and dual-mobility constructs. Still, they conclude that this constrained-liner approach, in the setting of a relatively well-positioned acetabular component, is a viable and durable THA revision option, especially for those “with a compromised abductor mechanism, recurrent instability, [and] a well-fixed and well-positioned acetabular component, for whom an acetabular revision would not be tolerated.”
Patient-Specific Instruments’ Effects on TKA Revision
Whenever we introduce new technology or techniques in hopes of improving orthopaedic surgery, at least one of two criteria should be met: The new technology should improve the outcome at a maintained cost, or it should decrease cost while maintaining at least an equivalent outcome. If neither of these conditions is met, we need to think twice about adopting it. To help us answer these “value” questions, we need relevant data. This is why studies such as the one by McAuliffe et al. in the April 3, 2019 issue of The Journal are so important.
The authors use the Australian Orthopaedic Association National Joint Replacement Registry to compare the rate of revision between 3 types of primary total knee arthroplasty (TKA):
- Those performed with image-derived instrumentation (IDI, i.e., patient-specific cutting jigs)
- Those performed using computer navigation
- Those using neither technology
McAuliffe et al. found no significant differences between groups in terms of cumulative percent revision at 5 years. Subgroup analysis revealed a higher rate of revision (hazard ratio [HR] 1.52, p = 0.01) for the IDI group relative to the computer-navigated group when patients were ≤65 years old. In addition, the IDI group had a much higher rate of patellar revision when patients received posterior-stabilized knees (HR of 5.33 when compared with the computer-navigated group, and HR of 4.16 when compared with the neither-technology group).
This study seems to suggest that whatever the benefits of IDI may be in terms of attaining a “proper” mechanical axis during TKA, IDI does not translate into a lower revision rate. And when these revision data are viewed in the face of the added costs associated with IDI, it makes little sense to advocate for the widespread use of this technology for TKA at this time.
While this study focused on TKAs, the take-home message can be extended. Orthopaedic surgery is by nature complex, requiring that multiple steps be performed in harmony to produce an optimal outcome. It is easy for us to focus on (and measure) a couple of key outcome variables and base our opinions of a technique’s or technology’s success on such findings. But when it comes to “novel” techniques and technological “breakthroughs,“ we need a lot of data on many different variables before we can make meaningful conclusions, change our practice, and advise our patients.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Benchmark Data on Aseptic Revision after Knee Replacement
The main advantage of joint registries is their large number of recorded procedures, ideally with very few patient “types” not represented in the database. This is the case with the Australian Orthopaedic Association National Joint Replacement Registry, which includes data on almost 100% of all joint replacements performed in Australia since 2002. In the February 20, 2019 issue of The Journal, Jorgenson et al. analyze almost 6,000 major aseptic total knee arthroplasty (TKA) revisions from a cohort of 478,000 primary TKAs registered between 1999 and 2015. This analysis provides robust benchmark data for patients and surgeons, although it comes too late for the 3% of patients who required such a revision surgery within the 15-year study period.
The authors found that fixed bearings were revised for aseptic reasons at a significantly lower rate than mobile bearings (2.7% vs 4.1%, respectively) and that patients <55 years old had an almost 8-fold higher revision rate compared to patients ≥75 years old ( 7.8% versus 1.0%, respectively). The study also found lower aseptic revision rates with minimally stabilized total knee prostheses compared to posterior-stabilized prostheses, and higher aseptic revision rates with completely cementless fixation relative to either hybrid or fully cemented fixation. These are valuable data for arthroplasty surgeons in terms of selecting implants and surgical techniques and for preoperative counseling of patients—especially younger ones. While many of these findings have been previously reported, these registry-based results add significant strength to published data.
Ideally, data such as these would be controlled for confounding variables such as surgeon experience and additional patient-specific variables such as activity demands and medical comorbidities. Still, these data provide useful prosthesis-specific factors for shared decision making with patients. We look forward to more helpful information from this and other national joint registries and encourage the continued growth of similar registries in other subspecialties.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Physical Parameters Beyond BMI Affect TKA Outcomes
It is well established that obese patients who undergo total joint arthroplasty have increased risks of complications and infections. But what about folks who are not obese, but are just generally large? Do they also have increased post-arthroplasty complications, compared to their smaller counterparts? That is the question Christensen et al. explored in a registry-based study in the November 7, 2018 edition of JBJS.
In addition to BMI, the authors examined 3 other physical parameters—body surface area, body mass, and height—to determine whether these less-studied characteristics (all contributing to “bigness”) were associated with an increased rate of various adverse outcomes, including mechanical failure and infection, after primary total knee arthroplasty (TKA). They evaluated data from more than 22,000 TKAs performed at a single institution and found that the risk of any revision procedure or revision for a mechanical failure was directly associated with every 1 standard deviation increase in BMI (Hazard Ratio [HR], 1.19 and 1.15, respectively), body surface area (HR, 1.37 and 1.35, respectively), body mass (HR, 1.30 and 1.27, respectively), and height (HR, 1.22 and 1.23, respectively). In this study, 1 standard deviation was equivalent to 6.3 kg/m2 for BMI, 0.3 m2 for body surface area, 20 kg for body mass, and 10.5 cm for height.
These findings, while not all that surprising, are enlightening nonetheless. The study shows that increasing height has a greater negative impact on TKA outcomes than previously thought. While I spend a lot of time counseling patients with high BMIs about the increased risks of undergoing a TKA (and while such patients can take certain actions to lower their BMI prior to surgery), I do not spend nearly as much time counseling patients who are much taller than normal about their increased risks (and height is not a modifiable risk factor). Nor do I spend much time thinking about a patient’s overall body mass or body surface area in addition to their BMI. This study will remind me not to overlook these less commonly examined physical parameters when discussing TKA with patients in the future.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Structural Allografts Can Work for Acetabular Defects in THA
Allograft bone is used often in orthopaedic surgery. However, the use of structural allografts to address large acetabular defects in total hip arthroplasty (THA) is not common. But it may become more so in light of the study by Butscheidt et al. in the August 15, 2018 issue of JBJS. The authors add to our knowledge about these relatively rare procedures by evaluating the incorporation of structural acetabular allografts into host bone among 13 complete pelvic explants containing allograft that had been in place for a mean of 13 years.
Using sophisticated imaging and histological techniques, the authors found that in 10 out of the 13 specimens retrieved, 100% of the interface was characterized by direct contact and additional overlap of the allograft bone and the host bone. The remaining 3 allografts showed direct contact along 25% to 80% of the interface. The authors found no correlation between ingrowth of the host bone into the allograft and the amount of time the allograft had spent in situ, leading them to surmise that “a large proportion of the incorporation process may be completed within the first weeks.”
Large, structural allografts are not commonly used for acetabular reconstructions, as most surgeons seem to favor other options. (See the JBJS Clinical Summary on “Managing Acetabular Defects in Hip Arthroplasty.”) While a postmortem study of 13 cases may not be “practice-changing,“ the Butscheidt et al. analysis does provide some detailed clarity as to what surgeons can expect from these large allograft reconstructions in terms of incorporation with host bone. Obviously, one limitation of this study is that structural allografts that never incorporated with the host bone probably failed early and would not be available for analysis in a long-follow-up retrieval study.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
More Evidence of Patient Benefits with Cross-Linked Polyethylene
In an OrthoBuzz post last year titled “Has Conventional Polyethylene Become Obsolete?,” we featured results from a small randomized trial that documented much-improved implant survival over 10 years with acetabular components made from cross-linked polyethylene (XLPE) compared with conventional polyethylene (CPE). In the August 1, 2018 issue of The Journal, we find further corroboration of the benefits realized by patients who receive XLPE acetabular components.
deSteiger et al. analyzed registry data involving more than 240,000 total hip arthroplasty (THA) patients and found markedly lower revision rates in those who received XPLE rather than CPE acetabular components. At a mean follow-up of 16 years, the cumulative percentage of revisions was 6.2% in the XPLE group versus 11.7% in the CPE group. Among patients <55 years of age at the time of THA, at 7 years there was a five-fold increase in revision rates for procedures done with CPE compared to those done with XLPE.
Because the authors observed that the between-group differences in revision rates became more pronounced over time, it is possible that this difference will continue to grow as more data is gathered. When we consider the vast number of THAs performed around the world each year, this XLPE-related decrease in revision rate could have a beneficial impact on millions of patients.
The documented success so far of XPLE is a clear case where understanding the nature of the original problem (polyethylene wear) and applying consistent and innovative research to find a solution have allowed patients worldwide to reap the benefits associated with THA, with some assurance that their hip replacement may, in fact, last for their rest of their life.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
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